Medical Transcription 01 Lecture Slides.pdf

Introduction to Medical Transcription I

1. Introduction to Medical Transcription I
MEDICAL TRANSCRIPTION
DR EBENEZER ODURO ANTIRI

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•Medical transcriptionists (MT) are supposed to produce the most accurate and
clear healthcare documentation possible, often on very tight deadlines.
•They must do so even if the physician has a heavy accent or dictates while
gulping down dinner, and even if loud conversations, a wailing baby, or
medical alarms are going off in the background.
•Under such conditions, the MT must reconcile the duty to transcribe verbatim
with the responsibility to produce high-quality reports and juggle both of those
tasks.
What Medical Transcriptionists Do?
ME D I C A L T R A N S C R I P T I O N I S T S

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•If the MT introduces a mistake into a patient’s medical record, such as
mistyping a medication name or dosage, the results can be serious—even
deadly.
•If the dictator makes a mistake and the MT catches it, the MT averts a potential
disaster for that patient.
•When you understand the true challenges and responsibilities associated with
being an MT, the job can quickly go from easy to intimidating.
•Yet these same challenges and responsibilities make the job interesting and
rewarding.
What Medical Transcriptionists Do?
ME D I C A L T R A N S C R I P T I O N I S T S

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•The job of a medical transcriptionist is to convert spoken medical
information into formal medical records. The dictations cover
everything from routine healthcare to life-threatening emergencies.
•The collection of the resulting documents becomes the patient’s
medical history.
The main roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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•Officially speaking, there are two formal, published descriptions of the functions
a medical transcriptionist performs:
1.Transcribe medical reports recorded by physicians and other healthcare
practitioners using various electronic devices, covering office visits,
emergency room visits, diagnostic imaging studies, operations, chart reviews,
and final summaries. Transcribe dictated reports and translate abbreviations
into fully understandable form. Edit as necessary and return reports in either
printed or electronic form for review, signature, or correction (U.S. Department
of Labor)
2.This job description organizes the MT profession into three career levels and
delves into the expected knowledge and job functions of each. It’s updated
from time to time; the current version is available on the AHDI website
(www.ahdionline.org) [Association for Healthcare Documentation Integrity
(AHDI)].
The main roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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•A lot of work done by transcriptionists revolves around a set of reports
dubbed the “Big Four”:
1.History and Physical Examination (H&P): The standard medical intake
report describing who you are and what your problem is. These reports
are dictated in new-patient office visits and acute-care facilities.
2.Consultation: What the specialist says before he sends the bill.
3.Operative Report: What happened under the knife.
4.Discharge Summary: How it all worked out in the end.
The main roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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•A lot of work done by transcriptionists revolves around a set of reports
dubbed the “Big Four”:
1.History and Physical Examination (H&P): The standard medical intake
report describing who you are and what your problem is. These reports
are dictated in new-patient office visits and acute-care facilities.
2.Consultation: What the specialist says before he sends the bill.
3.Operative Report: What happened under the knife.
4.Discharge Summary: How it all worked out in the end.
Big Four Reports
ME D I C A L T R A N S C R I P T I O N I S T S

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•Other common report types include the following:
1.Office/clinic note: Summary of an office visit, often just a paragraph or
two per patient and often dictated in a series as each patient is seen.
2.Independent medical evaluation (IME): An in-depth assessment of
past treatment and current condition, used to determine eligibility for
workers’ compensation and insurance benefits, as evidence in
personal injury or negligence lawsuits, and in other legal proceedings.
As you may expect from any document related to potential litigation,
these reports can go on for pages.
Other reports
ME D I C A L T R A N S C R I P T I O N I S T S

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3.Diagnostic report: Findings on X-rays, ultrasounds, CT scans, MRIs,
echocardiograms, sleep studies, and other diagnostic procedures.
They’re generally short and quantitative.
4.Emergency room reports
5.Physical therapy evaluations
6.Psychiatric assessments
7.Birth and death summaries
MTs take steps to enhance the clarity of reports as they transcribe them.
Other reports
ME D I C A L T R A N S C R I P T I O N I S T S

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1.Expanding medical acronyms, many of which can have different
meanings depending on context.
2.Applying the rules of English grammar and punctuation, regardless of
whether the dictator follows them.
3.Formatting the reports following standard guidelines and facility-
specific rules.
4.Tracking down and flagging potential errors, in addition to transcribing
spoken dictation.
Specific roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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5.MTs are increasingly handed the task of proofreading, editing, and
correcting medical documents created using speech recognition
technology (SRT).
6.MTs also must understand and comply with patient privacy and
confidentiality guidelines, including the federal HIPAA regulations that
define national standards for the management and protection of
health information.
These activities comprise the public face of MT work. They’re the aspects most apparent to those
on the outside looking in.
Specific roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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•The overriding mission of an MT is to produce a medical record that is
clear and accurate, even if the original source of information is not.
•It requires employing personal judgment and no small amount of patience
and determination.
•If all medical dictators spoke clearly, used good dictation equipment in
proper working order, clearly enunciated any jargon they used, and never
made mistakes, medical transcription would be a matter of typing fast and
referencing accurately.
•Modern computer programs could do it virtually unaided. However, the
real world is rarely neat and tidy, and neither is dictation.
Other roles of the MT
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•MTs clean up after dictators who are hampered by their equipment or
surroundings, fatigued, or just plain bad communicators.
•MTs apply knowledge of medical terminology, surgical procedures, lab
tests, medications, and human anatomy and physiology to correctly
transcribe often complex medical encounters.
•They detect and correct mistakes.
•An MT is sometimes the difference between a barely legible medical
record and a crystal-clear one.
Other roles of the MT
ME D I C A L T R A N S C R I P T I O N I S T S

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•The fellow human being whose care is being recorded is the ultimate
beneficiary of an MT’s efforts, but not the only one.
•Many dictators recognize this and appreciate the extra layer of support
and even safety MTs provide.
Conclusion
ME D I C A L T R A N S C R I P T I O N I S T S

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•High-quality healthcare documentation is critical to the survival of
healthcare facilities, too. It’s central to their ability to
•1. Increase patient safety
•2. Comply with extensive state and federal regulations
•3. Reduce risk exposure and potentially lower liability costs from
lawsuits
•4. Obtain payment from health-insurance providers, who want to know
exactly what treatment a patient has received and from who before
paying.
Conclusion
ME D I C A L T R A N S C R I P T I O N I S T S

16. Any questions?
Thanks!
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